The diagnosis of clinically significant oesophagealCandidainfections: a reappraisal of clinicopathological findings

Abstract

Aims Distinguishing true oesophageal Candida infections from oral contaminants is a common diagnostic issue. Historically, histological features believed to indicate true infection included epithelial invasion by pseudohyphae and intraepithelial neutrophils. Whether or not these features correlate with endoscopic lesions, symptoms and response to therapy has never been tested in a large cohort. The aim of this study was to determine whether specific histological features correlate with clinical and endoscopic findings when Candida is found in oesophageal biopsies. Methods and results We reviewed 271 biopsies in which Candida was detected. Cases were evaluated for the presence of desquamated epithelial cells, location/type of fungal forms, neutrophils, and ulceration. Medical records were reviewed for clinical history, endoscopic lesions, and response to antifungal therapy. Statistical analysis was used to determine whether any histological features significantly correlated with clinical variables. There were 120 males and 151 females with a mean age of 42 years. Fifty‐nine per cent had symptoms referable to the oesophagus, particularly dysphagia (36%). Most (73%) patients had abnormal endoscopic findings, with plaques, ulcers, or macroscopic evidence of oesophagitis. Seventy‐one per cent of patients with documented antifungal therapy showed symptomatic improvement. Overall, there was no statistically significant correlation between any histological feature and presenting symptoms, endoscopic findings, or response to therapy. Importantly, the lack of pseudohyphae, demonstrable invasion of intact epithelium or neutrophilic infiltrates did not exclude clinically significant infection. Conclusions We conclude that detection of Candida in oesophageal biopsies is always potentially clinically significant. Treatment decisions should be made on the basis of an integration of clinical, endoscopic and histological findings.

Diagnostic Delay in Patients With Eosinophilic Esophagitis Has Not Changed Since the First Description 30 Years Ago: Diagnostic Delay in Eosinophilic Esophagitis

“…In addition, endoscopic findings of whitish plaque-like lesions may be interpreted as esophageal candidiasis or as white exudates, both potentially expressing similar symptoms (35). Because the specificity of endoscopic diagnosis of Candida is at most 80%, histopathologic confirmation is essential (35,36). In addition, patients with esophageal motility disorders are at risk to develop esophageal candidiasis, adding another argument to obtain biopsies whenever the endoscopist sees white exudates and, especially, if the leading symptom is dysphagia (37).…”

“…In fact, it is of utmost importance to keep in mind that endoscopic features of EoE vary, ranging from classic features such as exudates, rings, edema, furrows, strictures, and narrowing or crepe-paper mucosae to completely normal-appearing mucosae (1,34). In addition, endoscopic findings of whitish plaque-like lesions may be interpreted as esophageal candidiasis or as white exudates, both potentially expressing similar symptoms (35). Because the specificity of endoscopic diagnosis of Candida is at most 80%, histopathologic confirmation is essential (35,36).…”

Clinicopathologic Characteristics of Esophageal Ectopic Sebaceous Glands: Chronological Changes and Immunohistochemical Analysis

“…2,18,19 Such chronological changes and varying appearance seemed to have been diagnostic pitfalls in endoscopy. When esophageal candidiasis is suspected on the basis of diffuse multiple yellowish-white elevated lesions in upper GE, 20 esophageal ectopic sebaceous glands should be harvested for differential diagnosis.…”

Prevalence, Predictive Factors, and Clinical Manifestations of Fungal Esophagitis in Children

“…Based on previous studies in adults (11,17,20–24) and children (6,25), symptoms of interest included dysphagia, odynophagia, retrosternal pain, epigastric pain, heartburn, cough, poor oral intake, nausea, vomiting, fever, lethargy, dehydration, weight loss, hematemesis, and poor oral hygiene. Patients without these symptoms were labeled “asymptomatic.” Documented comorbidities included gastro-esophageal reflux disease (GERD), eosinophilic esophagitis (EoE), malignancy, esophageal atresia and/or tracheoesophageal fistula (EA/TEF), and developmental delay.…”

“…Based on previous studies in adults (11,17,(20)(21)(22)(23)(24) and children (6,25), symptoms of interest included dysphagia, odynophagia, retrosternal pain, epigastric pain, heartburn, cough, poor oral intake, nausea, vomiting, fever, lethargy, dehydration, weight loss, hematemesis, and poor oral hygiene. Patients without these symptoms were labeled "asymptomatic."…”